Managing Change in the Context of a Community Health Information Infrastructure

Building health information infrastructure in communities is very challenging. One important reason is that it requires fundamental changes in how nearly everyone in health care does their job every day. Such massive change is never easy — and is never easy to manage. I’m assuming that since you’re reading this, you are involved in some fashion in trying to implement health information infrastructure in your community. Therefore, you are likely to find that your efforts, while well-intentioned, are not always welcome or productive. In an effort to help you navigate through the problems of managing change, I wanted to share some observations that may be helpful.

Resistance to Change
First and foremost, the world doesn’t want to be changed. Organizations are not “resistant to change,” but are established and designed purposely to prevent change. Processes are constructed for the express purpose of executing the same (previously successful) steps over and over — ostensibly to produce future success. This is totally rational. After all, you wouldn’t want an organization to invent a process for producing payroll checks from scratch every pay period. No — the efficient organization develops a process, documents it, hires staff to run it, and expects it to be done the same way every time. But this does not make the process amenable to needed change — quite the contrary, it is (and is designed to be) resistant to it. Just as a car simply will not fly unless you add wings, fighting against this basic characteristic of organizations is fruitless. If you want to change things in an organization, you’ll need to understand how to help reconfigure it — figuratively to “add wings” — to accommodate the new techniques. Simply pointing out the benefits of the “new way” is not an effective approach.

Change is not Welcome
Second, you should also recognize that as a change agent, you will not be welcomed, honored, or lauded — at least until sometime after the change is complete and proven successful (and maybe not even then). Even if what you are suggesting is the most reasonable, sensible, life-saving, and cost-effective idea, don’t expect congratulations followed by rapid adoption. Recall that it took the British Navy nearly 200 years to adopt the use of citrus fruit to prevent scurvy after it was clearly proven to be effective in a controlled trial. In order to adopt something new, people must first acknowledge — to some degree — that their current thinking is wrong. This is typically quite difficult — can you think of someone you know who doesn’t believe his or her current opinions are correct?

Likeability Trumps Good Ideas
A third key to success as a change agent is to recognize that your likeability is orders of magnitude more important than the desirable characteristics of whatever change you are proposing. It is obvious — but often overlooked — that organizational decisions are made by human beings. And human beings are not computers, and do not process facts and figures without emotion. Quite the contrary — they will typically use facts and figures to justify what they “feel” is right. And when they “feel” good about the person proposing change, they will be more likely to listen to the new idea and adopt it, even if it is not objectively terrific. So if you want to be a successful change agent, work hard on perfecting your social skills.

Change Must not be too Fast
Fourth, you must recognize that change has a definite “speed limit.” While computer systems can be changed quickly, “peopleware” cannot be rapidly reprogrammed. People are comfortable doing pretty much the same things day after day. If you impose too large a change, it will be immediately rejected — folks will literally refuse to be part of the new system. So incremental approaches are always best. In addition, it is important to keep everyone well-informed by letting them know what is going to happen and how it will affect them. Such communication must be repeated multiple times to be sure that it really reaches everyone.

Listening to Stakeholders is Key to Successful Change
Fifth, and perhaps most importantly, you must learn to listen — really listen — to all those who may be affected by the proposed change — and then you must act on what you hear. Listening is a mostly underdeveloped skill in today’s world. When communicating, most people are too busy thinking about their next response to really pay attention to what the other person is saying. There are many techniques that can help. One is simply repeating back what you thought you heard in the form of a question. For example, “did you say that it is more important for a change agent to be likeable than to have the best solution?” This forces you to listen and allows the other person to correct any misperceptions right away.

Once you are really listening, shape your plan based on what you’ve heard. Give people what they want — not what you think they need! And start meeting their objectives as quickly as possible so you can earn their trust. That trust will go a long way in later stages when things inevitably do not go so smoothly. Also, you should note carefully any potential negative impacts expressed to you, and work diligently to minimize them.

Summary
To summarize, here are some key lessons about being a “change agent”:

1) the world is organized for stability — not change, so recognize the need to reconfigure organizations as part of the change process

2) the change agent is not welcome, so expect an uphill battle

3) your likeability is vastly more important than your ideas, so master social skills.

4) change has a maximum rate that you cannot exceed, so don’t even try to do so

5) listening very carefully to the stakeholders and meeting their perceived needs is critical to success

As you pursue your own activities developing health information infrastructure, I hope these ideas are helpful. If you have additional lessons you’d like to share, please feel free to submit a comment.

Next time: Exposing the myths of health information infrastructure

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